Bleeding in pregnancy Flashcards
Define what antepartum haemorrhage is
This is bleeding from or into the genital tract occurring from ≥ 24 weeks + 0 until the end of the 2nd stage of labour (i.e. birth of the baby)
Bleeding in pregnancy can be split into 2 categories what are they?
- Bleeding in early pregnancy (<24weeks)
- And bleeding in late pregnancy (≥24weeks+0)
What is the other name given to bleeding in late pregnancy ?
Antepartum haemorrhage
Appreciate this:
Death from obsetric haemorrhage is very uncommon in the UK but globally it is very common consisting of up to 50% of maternal deaths each year
List the functions of the placenta
- It is the sole source of nutrition for the fetus from 6weeks
- Gas transfer occurs here
- Metabolism/ waste disposal for the fetus
- Hormone production - HPL (human chorionic sommatotropin) & human growth hormone (HGH-V)
- It is protective acting as a filter
- Very vascular but is normal expelled harmlessly
List the causes of antepartum haemorrhage
Dangerous ones:
- Placenta praevia
- Placental abruption
- Vasa praevia
Local causes:
- Cervical ectropion
- Polyps
- Cancer
- Infection e.g. cervicitis, STI
Other:
- Uterine rupture
- 40% of the time there is no apparent cause
List the other main differentials for APH ?
- Haemorrhoids = enlarged blood vessels (swellings) found inside/ around rectum & anus that can bleed
- Cystitis = inflammation of the bladder
- Heavy show; bloody show = the passage of small amount of blood/ blood-tinged mucus through the vagina near the end of pregnancy, it can occur just before labour or in the early stages of it
Quantifying APH, define the following:
- Spotting
- Minor haemorrhage
- Major haemorrhage
- Massive haemorrhage
- Spotting = staining, streaking or blood spotting noticed on underwear or sanitary protection
- Minor haemorrhage = blood loss < 50ml that has settled
- Major haemorrhage = blood loss of 50-1000ml, with no signs of clinical shock
- Massive haemorrhage = blood loss > 1000ml &/or signs of clinical shock
What are the clinical signs of shock?
- Low BP
- Altered mental state - reduced alterness, confusion, sleepiness
- Cold, moist skin, hands and eet may be blue or pale
- Weak or rapid pulse (or both)
- Rapid breathing (increased RR) & hyperventilation
- Decreased urine output
Define what placental abruption is and how common it is
- This is separation of a normally implanted placenta - it may be separated partially or totally before birth of the fetus
- It accounts for 30% of APH
How is placental abruption diagnosed ?
Clinically
Describe the pathology of placental abruption
- It occurs due to vasospasm followed by arteriole rupture
- Blood then escapes into the amniotic sac or further under the placenta & into the myometrium, causing tissue contraction & interruption of placental circulation which causes hypoxia and inturn a Couvelaire uterus
Note couvelaire uterus = a pregnant uterus in which the placenta has detacted prematurely with leakage (extravasation) of blood into the uterus myometrium
List the risk factors for placental abruption
- Unknown
- PET/HTN
- Trauma – blunt, forceful, domestic violence
- Smoking/Cocaine/Amphetamine
- Medical Thrombophilias/Renal diseases/Diabetes
- Poly-hydramnios, Multiple pregnancy, Preterm-PROM
- Abnormal placenta – The ‘Sick placenta’
- Previous abruption - recurrence 10%
What are the symptoms of placental abruption
- Severe abdo pain which is continuous (unlike labour pain which is intermittent due to contractions)
- Bleeding (may be concealed)
- Backache
- Preterm labour
- May present with maternal collapse
What are the signs of placental abruption ?
- Unwell distressed patient
- Uterine tenderness
- Woody hard uterus
- Vaginal bleeding (may be small or large volume as bleeding can be concealed so signs may be inconsistent with observed blood loss i.e. small blood loss but severe signs)
- Fetal parts difficult to identify
- Uterus large for dates (LFD) or normal
- May be in pre-term labour
- FH (fetal heart) bradycardia/absent (IUD)
- CTG shows irritable uterus - 1 contraction/min, FH: loss of variability, deccelerations seen
What are the keys steps in management of a women presenting with placental abruption ?
- Resuscitate the mother
- Assessment/ diagnosis of the condition
- Delivery
- Management of complications
What is done to resuscitate a mother with placental aburption ?
- ABCDE assessement
- 2 large bore cannulas
- FBC, clotting screen, LFT’s, Us & Es, Cross-matching, Kleinhauer test
- IV fluids
- Catheterise and monitor
What is done to in the assessment of a mother with placental aburption ?
- Assess FH on CTG
- Perform U/S if no FH on CTG to evlaute the FH
- No reliable diagnostic test: U/S will fail to detect 3/4 of abruptions so diagnosis of abruption is primarily clinical
What the delivery management of a women with palcental abruption ?
For moderate & severe abruption/APH:
- Women with APH & associated maternal &/or fetal compromise are required to be delivered immediately by C-section or artificial rupture of membranes & induction of labour
Minor aburption/APH:
- Expectant management only used for minor cases (all time for steroid cover)
List the potential maternal complications of placental abruption
- Hypovolaemic shock
- Anaemia
- PPH
- Renal failure from renal tubular necrosis
- Coagulopathy (if DIC develops)
- Infection
- Thromboembolism
- Prolonged hosp stay
- Death (rare)
List the potential fetal complications of placental abruption
- IUD (14%)
- SGA & IUGR
- Prematurity
- Hypoxia
When are steroids given to pregnant women ?
- A single course of steroids is given to women between 24+0 and 34+6 weeks who are at risk fo preterm birth
Following APH from aburption or unexplained origin, if the women is still pregnant and has not given birth what should be done ?
- Pregnnancy should be reclassified as high risk and Serial U/S for fetal growth should be performed
What investigation should be avoided if placenta praevia is a possibility for the cause of APH?
Vaginal examination as it can cause catastrophic bleeding
What is given to help prevent placental abruption ?
- Try to stop women smoking, using cocaine or amphetamines
- Women with thrombophilia (anti-phos syndrome) given LMWH + low dose aspirin
- Women at risk of abruption not those who have APS given low dose aspirin
Define what placenta praevia is
This is where the placenta is partially or totally implanted in the lower uterine segment known as a ‘low lying placenta’
What percentage of APH does placenta praevia account for ?
20%
What are the risk factors for developing placenta praevia ?
- Previous placenta praevia
- Asian
- Smoking
- Previous termination
- Multiparity
- Advanced maternal age >40
- Mutplie pregnancies
- Assisted conception
- Deficient endometrium due to - uterine scar, endometritis, manual removal of placenta, currettage, submucous fibroid
State the classification of placenta praevia (I to IV)
- I - placenta reaches lower segment but not the internal os
- II - placenta reaches internal os but doesn’t cover it
- III - placenta covers the internal os before dilation but not when dilated
- IV - placenta completely covers the internal os
State the classification of placenta praevia into major and minor
- Minor praevia = if the leading edge of the placenta is in the lower uterine segment but not covering the cervical os
- Major praevia = if placenta lies over the internal cervical os
What are the signs and symptoms of placenta praevia
- Painless vaginal bleeding occurring > 24weeks
- Bleeding usually provoked by coitus (sexual intercorse)
- Bleeding can range from minor e.g. spotting to severe
- Patients condition is directly proportional to amount of observed bleeding (unlike abruption)
- Uterus is soft & non-tender
- Presenting part is high
- Malpresentation e.g. breech, transverse, oblique (if placenta is in an odd position so will the baby be)
- CTG usually normal
How is placenta praevia diagnosed ?
Transvaginal U/S
- Note check their anomaly scan at 20 weeks as this often picks it up
- Followed up and then confirmed at 32-34 week scan
What are the 3 keys steps in the management of a pregnant women bleeding from placenta praevia ?
- Admit & resuscitate
- Monitor FH
- Delivery
In a women bleeding from placenta praevia what resucitative measures are required ?
- 2 large bore cannulas
- FBC, clotting screen, LFT’s, Us & Es, Kleihauer test, X-match 4-6 units of RBC’s
- May need major haemorrhage protocol
- IV fluids or transfusion
- Anti-D if Rh -ve
(basically same as for placental abruption)
In a women bleeding from placenta praevia what FH monitoring is required ?
- CTG
- U/S carried out if FH not detected on CTG (same as placental abruption)
In a women bleeding from placenta praevia what are the management options for delivery ?
Conservative/expectant management:
- Should be an inpatient for at least 24hrs until bleeding has stopped
- Monitor FH with CTG after 28 weeks
- Steroids course given if between weeks 24 to 34+6
- MgSO4 given if planning delivery between 24-32 weeks
- Serial U/S also recommended
- On pelvic rest, avoiding sexual intercourse
If not stable then may need to do C-section
What determines the mode of delivery in women with placenta praevia
- C-section (with consultant present) done if placenta is < 2cm from the cervical os
- Vaginal delivery done if placenta > 2cm away from cervical os & no malpresentation
Major bleeding may require preterm delivery
C-section at 37 - 38 weeks if there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta
C-section at 38-39 weeks if there has not been bleeding in pregnancy
What is the association of increasing the number of C-sections you have had done and placental abnormalities
The risk of placenta praevia & accreta both increase with the number of C-sections you have had done
Read over abruption vs praevia:
Abruption:
- Shock out of keeping with visible blood loss
- Pain constant
- Tender, tense uterus
- Normal lie & presentation of baby
- FH - absent/distressed
- Coagulation problems associated
- Beware of PET, DIC, anuria
Praevia:
- Shock in proportion to visible blood loss
- No pain
- Uterus soft & non tender
- Lie & presentation of baby may be abnormal
- FH usually normal
- Coagulation problems rare
- Small bleeds before large
Define what placenta accreta is
Planceta accreta is the general term for whe the plaenta invades & is inseperable from the uterine wall. There is 3 subtypes:
- Placenta accreta = placenta attaches to the myometrium
- Planceta increta = placenta invades into the myometrium
- Placenta pancreta = placenta invades through the perimetrium (serosa)
What are the 2 major risk factors for placenta accreta ?
- It occurs in 5-10% of placenta praevias
- Risk of it increases with increasing no. of C-sections
When does placenta accerta become a problem?
It becomes a problem during delivery when the placenta does not completely separate from the uterus & is then followed by massive obstetric haemorrhage (>3L expected)
How is placenta accreta diagnosed ?
1st line = U/S +/- MRI
Antenatal MRI can be used as well to assess depth of invasion etc
What is the management of placenta accreta ?
- Prophylactic internal iliac artery balloon occlusion done
- Then it is generally recommended a planned cesarean hysterectomy is done after weeks 36-37 if possible
- Conservative management should not be done if women is already bleeding
Define what uterine rupture is
Defined as a full thickness opening of the uterus
What are the risk factors for uterine rupture?
- Previous C-section/uterine surgery
- Multiparity & use of syntocin
- Obstructed labour
- Usually occurs in labour
What are the signs and symptoms of uterine rupture ?
- Severe abdo pain
- Shoulder-tip pain
- Maternal collapse
- PV bleeding (vaginal)
- Intrapartum loss of contractions
- Fetal distress/ IUD
- Puritanism - vomiting, pain or abdo tenderness & shock
What is the management of uterine rupture ?
Urgent resuscitation & surgical management
What is the resuscitation management of uterine rupture ?
- 2 large bore cannulas
- FBC, clotting screen, LFT’s, Us and Es, Kleihauer test, X-match 4-6 units of RBC’s
- May need major haemorrhage protocol
- IV fluids or transfusions
- Anti-D if Rh -ve
Same as all other resus management
What is the surgical management of uterine rupture ?
Laparotomy (if uterus rupture small repair, if large hysterectomy may be done) & deliver the baby via C-section
Define what vasa praevia is
Defined as fetal vessels coursing through the membranes over the internal cervical os, unprotected by placental tissue or umbilical cord
What are the risk factors for vasa praevia ?
- Placental anomalies such as bilobed placenta where fetal vessels run through the membranes joining the separate lobes together
- Placenta praevia
- Multiple pregnancy
- IVF
How does vasa praevia often present ?
- Presents with fresh vaginal bleeding at the time of membrane rupture + FH abnormalities - deccelerations, bradycardia, sinusoidal tract or fetal demise
- Note blood volume may be very small as fetal blood volume 200ml at term ==> small amounts of blood can have serious consequences
What is the fetal mortality rate of vasa praevia ?
60%
How is vasa praevia diagnosed ?
It may be diagnosed on antenatal U/S + doppler
What is the management of vasa praevia ?
C-section is fetal compromise/ demise present
When taking a history about APH what should you ask about ?
- Bleeding - quantify
- Pain - SCORATES
- Contractions - freq and strength
- Fetal movements - change from normal ?
- Post-coital - pain or bleeding ?
- Smear history
- Antenatal scan history - U/S
Go over the antenatal admission criteria for APH
Any history of acute bleeding 23 – 32 weeks:
- Min stay of 24 hours clear of bleeding
Recurrent bleeding after 28 weeks:
- Min stay of 72 hours
- Consider need to be admitted until delivery
Any bleeding after 32 weeks:
- Min stay of 72 hours
- Consider need to be admitted until delivery
Major placenta praevia after 36 weeks with no bleeding:
- Consider the social circumstances
- Consider other obstetric factors
- Consider need for admission until delivery
- Consultant decision
Should steroids be given to a women who presents with APH ?
Single course is given if presents between 24 to 36+6 weeks (greatest effect between 24 to 34+6 but still given up until 37 weeks essentially)
Should antenatal care be adapted for women with APH ?
Yes any from abruption, praevia or unclassified are reclassified as high risk and have consultant led care with serial U/S for fetal growth measurements
Go over the principles of labour & delivery
- If fetal death diagnosed then vaginal delivery
- If fetal compromise then C-section
- Women with APH & associated maternal &/or fetal compromise are to be delivery immediately
What is the purpose of steroids prior to delivery in preterm babies ?
- It promotes fetal lung surfactant production
- It ↓ neonatal RDSby up to 50% if administered 24-48h before delivery
- Betamethasone preferred to Dexamethasone
- 1 course = 12mg Betamethasone IM X2 injections 12 hours apart
